PCI Use Variation 'Will Always Be With Us' or Will It?

Persistence says other decision-making processes are at work, and that's okay, cardiologist argues

Varying opinions on what is appropriate care in the cath lab might not be inherently bad, as long as physicians work to make every procedure safe and of value to the patient, an interventionalist concluded in a review of appropriate use criteria performance.

"The developers of these Appropriate Use Criteria (AUC) stated their goal was to outline a schematic for an efficient use of resources when confronted with a variety of clinical problems, H. Vernon Anderson, MD, of University of Texas Health Science Center in Houston, wrote in JAMA Cardiology

"The AUC, then, are just one more formulation of evidence designed to help clinicians and patients make informed choices; they are meant to complement, not replace, the guidelines. Both the guidelines and AUC can provide insights but from different perspectives," he argued.

His opinion piece cited a 2015 study that found that use of inappropriate, non-acute percutaneous coronary intervention (PCI) was halved in the 5 years since the 2009 publication of the AUC for Coronary Revascularization. However, marked hospital-level variation persisted in rates of what the AUC dubbed inappropriate catheterization procedures.

That study used the CathPCI data set from the National Cardiovascular Data Registry, the world's largest PCI registry.

What was "fascinating" but inexplicable, said Anderson, was the observation that hospital-level variation in inappropriate PCI did not budge over the study period. "If interventionalists were moving toward greater adherence to AUC and the inappropriate category declined, hospital-level variation should narrow rather than stay constant," he noted.

Then again, he suggested, perhaps variations "will always be with us." The AUC developers themselves had "internal variations over the ratings of the clinical scenarios for coronary revascularization, perhaps suggesting that there are more widespread and fundamental decision-making forces at work underneath."

"We are called on to demonstrate not only that individual procedures are safe and effective in their immediate outcomes but also that they have value to patients over longer periods compared with alternative treatments," he concluded.

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